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Transcatheter aortic valve implantation vs. surgical aortic valve replacement for treatment of symptomatic severe aortic stenosis: an updated meta-analysis

Comment by Dejan Milasinovic

European Heart Journal, Volume 40, Issue 38, 7 October 2019, Pages 3143–3153

Valvular Heart Disease


Aim

To compare the effects of transcatheter aortic valve implantation (TAVI) vs. surgical aortic valve replacement (SAVR) across different hitherto studied patient groups.

Methods

This aggregate-data meta-analysis included 7 randomized controlled trials with the overall population of 8020 (4014 TAVI vs. 4006 SAVR), combining patients at high, intermediate and low surgical risk. The primary outcome was all-cause mortality up to 2 years (and up to the longest available follow-up within each study).

Main results

  • In the overall population, TAVI reduced all-cause mortality compared with SAVR (HR 0.88 (95% CI 0.78–0.99), P = 0.030).
  • The rate of stroke was lower in patients undergoing TAVI, albeit with no difference in terms of disabling stroke for TAVI vs. SAVR.
  • TAVI was associated with less new-onset atrial fibrillation, major bleeding and acute kidney injury, whereas SAVR resulted in a lower rate of major vascular complications.
  • Post-procedural permanent pacemaker implantation was more frequent after TAVI (more so in patients treated with self-expandable valves).

Main messages

The main finding of this meta-analysis is that TAVI poses a survival benefit compared with SAVR across the whole spectrum of baseline surgical risk in patients with symptomatic severe aortic stenosis (AS). To this end, the authors highlight the consistency of the observed results in terms of low statistical heterogeneity among the included trials for the primary endpoint of all-cause mortality, and no significant interaction between the subgroups of surgical risk. Moreover, the benefit of TAVI was even accentuated when utilizing transfemoral vs. transthoracic route (as shown by the significant interaction between those two TAVI access sites on the all-cause mortality; p=0.032).

With these results, the use of TAVI for a majority of patients with symptomatic severe AS may seem to be warranted, albeit taking into account the future research in terms of transcatheter heart valve (THV) durability and the impact of new technical and technological developments in both the interventional and surgical arena.

The content of this article reflects the personal opinion of the author/s and is not necessarily the official position of the European Society of Cardiology.